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Could you be so kind as to quote the source of that data? It is difficult to come by.
End of Oxycontin?
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Avinza- SODAs technology. 10% IR / 90% ER
Oxycontin- Dual polymer Matrix 38% IR / 62% ER
Kadian- 100% ER
Methadone- 100% IR with unpredictable plasma half life, predictable 6hr analgesic efficacy half life
Support Care Cancer (2003) 11:8492
Mellar P. Davis
James Varga
Duke Dickerson
Declan Walsh
Susan B. LeGrand
Ruth Lagman
Normal-release and controlled-release oxycodone: pharmacokinetics,
pharmacodynamics, and controversy.
Pharmacology of CR oxycodone
Unlike NR oxycodone, CR oxycodone is absorbed in a
bi-exponential fashion. There is a rapid phase with a
mean half-life of 37 min, accounting for 38% of the
dose, and a slow phase with a half-life of 6.2 h, which
accounts for the residual 62% [17]. Overall, oral bioavailability
is equivalent to that of NR oxycodone [15].
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THANK YOU!!!!!!!!!!!!!!!!!!!!!!!
I have searched for years for that info!!!!!!
I have searched for years for that info!!!!!!
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LMAO.....are you lecturing for both A and K?....also, typo on the Methadone being IR instead of ER?
T
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A little here, a little there, it is all good.
Methadone analgesia lasts 6 hrs. Plasma half life ranges from 13-130 hours.
In my book, that's a short acting medication. I rarely use it in patients. It's use is to fight insurance companies to get a real long acting on board. I provide them with the FDA statement, the DAWN and SAMHSA data- they give me carte blanche to do the riht thing for my patients.
Methadone analgesia lasts 6 hrs. Plasma half life ranges from 13-130 hours.
In my book, that's a short acting medication. I rarely use it in patients. It's use is to fight insurance companies to get a real long acting on board. I provide them with the FDA statement, the DAWN and SAMHSA data- they give me carte blanche to do the riht thing for my patients.
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That's cause they don't know me.
Methadone is not IR or ER. It acts like an IR in it's efficacy, but it acts like an ER in it's plasma half-life. If we are considering the clinical utility of this drug- it is very narrow becuase of it's ability to help pain for 6 hours and it's ability to create side effects including prolonged QTc 130 hours later.
http://www.fda.gov/cder/drug/infopage/methadone/default.htm
http://www.legalsideofpain.com/index.cfm?fuseaction=news.article&articleId=461
SAMHSA data, NIDA data, DAWN data need to be evaluated carefully.
I'm anti-methadone as a first or second line opioid. I have an informed consent specific for methadone due to the inherent dangers that separate it from other opioids.
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I have prescribing methadone since the 80s. Great drug. Seems to work better for nerve pain than other opioids. I have people on dosing intervals ranging from q6 to q12, same as OxyContin, which is not a 12 hour drug for most people.
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Hate to resurrect this thread for something slightly off topic, but is this Porter and Jick Letter to the Editor from 1980 the basis of the claim, repeated ad naseum in so many articles, statements, and texts, that that the chance of addiction for opioids is less than 1%?
Here is another link to the article:
http://www.uofapain.med.ualberta.ca/documents/AddictionRareinPatientstreatedwithNarcotics.pdf
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You got it! The link provides a photocopy of the entire letter to the editor.
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The facts on substance abuse incidence:
Tightly controlled studies of pain patients 1%
US population over age 12 4.7% NHDUS study 2005
Pain patients seen in pain clinics and in PCP practices: Average 30%
Tightly controlled studies of pain patients 1%
US population over age 12 4.7% NHDUS study 2005
Pain patients seen in pain clinics and in PCP practices: Average 30%
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Pain Patient Substance Abuse Rates: The Studies
34% abuse rate in chronic pain populationClin J Pain 1997 Jun;13(2):150-5
Prescription opiate abuse is seen in 24-33% of chronic non-cancer pain patients J Gen Intern Med 2002 Mar;17(3):173-9 Use of opioid medications for chronic noncancer pain syndromes in primary care.
Prescription narcotic abuse is seen in 25% of a chronic pain clinic population Pain Physician 2001 July
24% of spinal cord injury patients report abusing prescription abusable drugs Int J Addict 1992 Mar;27(3):301-16
50% of chronic headache patients had abuse of narcotics over a 3 year period."Patients used medications inappropriately, received them from more than one physician, tried to fill prescriptions early, or claimed to lose them and requested more than prescribed. Neurology. 2004;62:1687-1694
32% Substance Abuse Rate in Chronic Pain Patients Predictors of opioid misuse in patients with chronic pain: a prospective cohort study. BMC Health Serv Res. 2006 Apr 46:46.
20-60% Substance Abuse and Illicit Drug use rates depending on insurance class (Medicaid was 60%) J Ky Med Assoc. 2005 Feb;103(2):55-62
24% of patients being treated for chronic low back pain (Ann. Intern. Med. 2007 Jan 16;146(2):116-27)
34% abuse rate in chronic pain populationClin J Pain 1997 Jun;13(2):150-5
Prescription opiate abuse is seen in 24-33% of chronic non-cancer pain patients J Gen Intern Med 2002 Mar;17(3):173-9 Use of opioid medications for chronic noncancer pain syndromes in primary care.
Prescription narcotic abuse is seen in 25% of a chronic pain clinic population Pain Physician 2001 July
24% of spinal cord injury patients report abusing prescription abusable drugs Int J Addict 1992 Mar;27(3):301-16
50% of chronic headache patients had abuse of narcotics over a 3 year period."Patients used medications inappropriately, received them from more than one physician, tried to fill prescriptions early, or claimed to lose them and requested more than prescribed. Neurology. 2004;62:1687-1694
32% Substance Abuse Rate in Chronic Pain Patients Predictors of opioid misuse in patients with chronic pain: a prospective cohort study. BMC Health Serv Res. 2006 Apr 46:46.
20-60% Substance Abuse and Illicit Drug use rates depending on insurance class (Medicaid was 60%) J Ky Med Assoc. 2005 Feb;103(2):55-62
24% of patients being treated for chronic low back pain (Ann. Intern. Med. 2007 Jan 16;146(2):116-27)
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20-60% Substance Abuse and Illicit Drug use rates depending on insurance class (Medicaid was 60%) J Ky Med Assoc. 2005 Feb;103(2):55-62
Was this Lax's data?
I was so impressed of the outright abuse risk in the Medicaid population, I dropped Medicaid. Just kidding- I never took Medicaid as it cost more to file the claim than Medicaid was willing to pay.
Was this Lax's data?
I was so impressed of the outright abuse risk in the Medicaid population, I dropped Medicaid. Just kidding- I never took Medicaid as it cost more to file the claim than Medicaid was willing to pay.
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Yes, Lax et al....
Makes me glad I live in Indiana instead of Kentucky.
We had the same experience with the Medicaid population....always pushing the envelope of what was acceptable behavior with respect to using opiates, frequently lost scripts or having them stolen, selling the drugs rather than using them, etc.
Makes me glad I live in Indiana instead of Kentucky.
We had the same experience with the Medicaid population....always pushing the envelope of what was acceptable behavior with respect to using opiates, frequently lost scripts or having them stolen, selling the drugs rather than using them, etc.
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"Opioid abuse" probably meaning "patient mentioned that pain was not being sufficiently controlled -- MUST BE ADDICT!"
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No, addiction is probably indeed uncommon in the pain population, but substance abuse is very common. Substance abuse includes illicit drug use, repeated overuse of prescription medications, etc.
I do not believe there is such a thing as pseudoaddiction....it is a buzzword created by industry to justify physicians prescribing more and more drugs and is also a legitimization of the loss of control of his practice by the physician.
I do not believe there is such a thing as pseudoaddiction....it is a buzzword created by industry to justify physicians prescribing more and more drugs and is also a legitimization of the loss of control of his practice by the physician.
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I agree with Algos that abuse is quite common, but of course it depends on what you consider abuse. There is probably a subcategory here of what Passik calls "chemical copers". I think there are a lot of those, and they are often the ones who are the biggest problems.
I think many of the behaviorly problematic patients we see are borderline personalities and they use the meds to deal with the pain of everyday living , which makes them chemical copers. They do not tolerate any type of frustration, including unrelieved pain. They are the ones who complain about having to wait extra time in the waiting room or for a procedure. When they use up their meds early they are the ones who get nasty with the staff when they can't get a refill.
I do believe in pseudoaddiction. I, for one, would beg, borrow, or steal to get out of agonizing pain. If you do that, you are exhibiting pseudoaddictive behavior. There is probably a better term for this, but I think it does serve a purpose to counter the improperly applied term "addiction" to people who are merely under-treated. I think it's a good term from that point of view, but a bad one when hijacked by the drug companies for commercial exploitation.
I think many of the behaviorly problematic patients we see are borderline personalities and they use the meds to deal with the pain of everyday living , which makes them chemical copers. They do not tolerate any type of frustration, including unrelieved pain. They are the ones who complain about having to wait extra time in the waiting room or for a procedure. When they use up their meds early they are the ones who get nasty with the staff when they can't get a refill.
I do believe in pseudoaddiction. I, for one, would beg, borrow, or steal to get out of agonizing pain. If you do that, you are exhibiting pseudoaddictive behavior. There is probably a better term for this, but I think it does serve a purpose to counter the improperly applied term "addiction" to people who are merely under-treated. I think it's a good term from that point of view, but a bad one when hijacked by the drug companies for commercial exploitation.
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The problem is you're applying the term "addiction" to people who are undertreated. Often you are just misreading signals and thinking that it is drug-seeking when it is not. I am on the other side of the argument because I am a chronic pain patient and speak to other patients all the time. I know how poorly they've been treated. And no, we're not all crybabies who don't know how to cope. You try being in pain 24/7, surrounded by people who either don't care or don't understand.
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Undertreatment of pain is usually a code word for "we want more narcotics" in spite of virtually no evidence chronic opiate prescribing works for chronic pain. The behavioral issues surrounding the prescribing of opiate narcotics is the primary determinant on whether the patient is a candidate for increased doses and if they cannot control their use with low doses of narcotics, they certainly cannot control their use of high dose, and potentially lethal narcotics. The drug companies wrongly assert there is no ceiling on the amount of pain medicines that should be prescribed and dupe the naive pain patient into thinking doctors will escalate their doses into the stratosphere just because the patient says they hurt. Those of us in the trenches that deal with the patients that overdose or are seeing 4 doctors for pain medications or don't understand why they can't double or triple their daily dose of continuous release oxycodone because they hurt. We deal with the nasty side of people that don't give a flip about the nation's drug laws and will therefore not give a flip about our clinic policies on opiates. We treat patients that are double dipping at methadone treatment centers without our knowledge, that sell their pills on the street for profit, and who will make up any possible story in order to obtain more drugs. One patient today in my practice was summarily discharged when he was discovered to be obtaining narcotics from at least one other pain clinic 700 miles away on a monthly basis then denied it, even after we sent our photograph of the patient to the nurse at the clinic (yepper, those photos in the EMRs are handy) and had an exact match on the social security card including the scribbles the patient had made on the card. He was also discovered from yet another clinic to be getting drugs and doing cocaine.
Of course there are legitimate pain patients, but one bad apple costs us time and $$$ in making telephone calls to other clinics, comparing notes, writing discharge letters, and informing the police regarding the subterfuge. It is part of what we do to insure compliance, but it does not make us happy about trying to figure out who is scamming and who is not. Nor will we cheerfully prescribe unlimited quantities of narcotics for "undertreated pain". One of the greatest misunderstandings of pain patients is that the presence of pain does not equate to an absence of narcotics. Oh, I know the bleeding heart pain patient advocates will say it is the right of pain patients to be medicated into oblivion if it is their wish or state vaguely "doctors are not doing enough to treat pain" without having any suggestion (other than massive doses of narcotics) of what would constitute such miraculous treatment.
I am as much an advocate of the prescription of narcotics as anyone in the pain community but it is an assault to our senses for a pain patient to come into a physicians forum crying foul because pain physicians will not succumb to the rhetoric of "undertreated pain" . We do what we can to treat pain with narcotics for those that demonstrate they have enough common sense and self control to use them safely, but we are happily constrained by medical ethics, laws, and the hippocratic oath.
Of course there are legitimate pain patients, but one bad apple costs us time and $$$ in making telephone calls to other clinics, comparing notes, writing discharge letters, and informing the police regarding the subterfuge. It is part of what we do to insure compliance, but it does not make us happy about trying to figure out who is scamming and who is not. Nor will we cheerfully prescribe unlimited quantities of narcotics for "undertreated pain". One of the greatest misunderstandings of pain patients is that the presence of pain does not equate to an absence of narcotics. Oh, I know the bleeding heart pain patient advocates will say it is the right of pain patients to be medicated into oblivion if it is their wish or state vaguely "doctors are not doing enough to treat pain" without having any suggestion (other than massive doses of narcotics) of what would constitute such miraculous treatment.
I am as much an advocate of the prescription of narcotics as anyone in the pain community but it is an assault to our senses for a pain patient to come into a physicians forum crying foul because pain physicians will not succumb to the rhetoric of "undertreated pain" . We do what we can to treat pain with narcotics for those that demonstrate they have enough common sense and self control to use them safely, but we are happily constrained by medical ethics, laws, and the hippocratic oath.
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Primum non nocere.
Although we should recognize the right of patients to have their pain controlled, we also must recognize that not all patients are candidates for all therapies. Those who can't control their use of narcotics or who use the drugs for other than their intended purpose have an adverse risk/benefit ratio.
I am also a firm believer in opioid-induced hypersensitivity. I think you can tell when you're in the hypersensitivity phase. That is when they complain that they are sleepy all day but can't sleep at night, the duration of action of the drug starts to get shorter, and the medicine "doesn't work any more". There is no progress in ADLs and mood after dose escalations. Of course it could also be depression, and often depression and hypersensitivity are two sides of the same shovel that I've dug the hole with.
I agree with Algos that one of these problem patients can drag down the whole office. It's easy to get angry with them, even though you know they have a disease. The problem with abusers/addicts is that their disease causes behaviors that harm others. People with renal failure usually don't steal your TV set or forge scripts. No one ever yells at you and says "Dammit, Mike, you've got hypothyoidism."
But they will yell at you for having a disease like drug addiction because of the perception that you could do something about it if you wanted to, which is simplistic and naive. Addictions are hard to beat and even in motivated patients there are relapses. I tell people I am an expert on quitting smoking because I have done it 5 times (smoke-free for 19 years now).
Nonetheless, unless and until they are ready to accept the diagnosis and want to treat it, there is little point in keeping abusers/addicts in the practice. Usually they leave of their own accord when the drugs stop flowing.
Thanks ever so much, Dr. Portenoy.😡
Although we should recognize the right of patients to have their pain controlled, we also must recognize that not all patients are candidates for all therapies. Those who can't control their use of narcotics or who use the drugs for other than their intended purpose have an adverse risk/benefit ratio.
I am also a firm believer in opioid-induced hypersensitivity. I think you can tell when you're in the hypersensitivity phase. That is when they complain that they are sleepy all day but can't sleep at night, the duration of action of the drug starts to get shorter, and the medicine "doesn't work any more". There is no progress in ADLs and mood after dose escalations. Of course it could also be depression, and often depression and hypersensitivity are two sides of the same shovel that I've dug the hole with.
I agree with Algos that one of these problem patients can drag down the whole office. It's easy to get angry with them, even though you know they have a disease. The problem with abusers/addicts is that their disease causes behaviors that harm others. People with renal failure usually don't steal your TV set or forge scripts. No one ever yells at you and says "Dammit, Mike, you've got hypothyoidism."
But they will yell at you for having a disease like drug addiction because of the perception that you could do something about it if you wanted to, which is simplistic and naive. Addictions are hard to beat and even in motivated patients there are relapses. I tell people I am an expert on quitting smoking because I have done it 5 times (smoke-free for 19 years now).
Nonetheless, unless and until they are ready to accept the diagnosis and want to treat it, there is little point in keeping abusers/addicts in the practice. Usually they leave of their own accord when the drugs stop flowing.
Thanks ever so much, Dr. Portenoy.😡
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the only pain patients who i consider ever close to being undertreated are terminal cancer patients - especially those with bone disease
all those other chronic pain patients aren't undertreated from my point of view - they have just "failed" treatment... if you have chronic pain and everything has been tried, and vicodin BID gives you significant relief and your function improves with minimal to no side-effects then great - if you are on oxycontin 80 TID and still feel pain, then therefore you aren't undertreated - you are just not narcotic-responsive... treatment: wean off oxycontin.
it is amazing how many times i see those "chemical copers" who are on oxycontin 80 TID for the treatment of a 20yr hx of chronic daily headaches who swear that they need an increase because it doesn't give them any relief whatsoever... My first comment: "if it isn't giving you any relief then we should discontinue it" - their classic response is "oh, but it does give me relief" - then i respond "that's not what you said a minute ago" - then they blankly stare at me (realizing that they are going to have to perform a bit better)... then they say "it lets me function"... then i ask "why do you think this ridiculous amount of narcotic needs to be increased" ... response: "i still have pain".... then i point out that this is obviously not a treatment that is working for them... then they point out that I am under-treating them... then i point out that their PCP is over-treating them with a medication that doesn't appear to work... then they either listen to me and follow my instructions or they leave.
do cardiologists who refuse to escalate metoprolol beyond 200mg daily undertreat their BP patients? i don't think so...
under-treatment is way over-used when it comes to narcotics and in my opinion it represents the fixation by some chronic pain patients (and the narcotic drug industry) that if they don't get specifically an increase in narcotics they are being under-treated... some are offended that i would consider adding an NSAID or Neurontin or a TENS unit. I guess they went to medical school and are boarded in pain management...
all those other chronic pain patients aren't undertreated from my point of view - they have just "failed" treatment... if you have chronic pain and everything has been tried, and vicodin BID gives you significant relief and your function improves with minimal to no side-effects then great - if you are on oxycontin 80 TID and still feel pain, then therefore you aren't undertreated - you are just not narcotic-responsive... treatment: wean off oxycontin.
it is amazing how many times i see those "chemical copers" who are on oxycontin 80 TID for the treatment of a 20yr hx of chronic daily headaches who swear that they need an increase because it doesn't give them any relief whatsoever... My first comment: "if it isn't giving you any relief then we should discontinue it" - their classic response is "oh, but it does give me relief" - then i respond "that's not what you said a minute ago" - then they blankly stare at me (realizing that they are going to have to perform a bit better)... then they say "it lets me function"... then i ask "why do you think this ridiculous amount of narcotic needs to be increased" ... response: "i still have pain".... then i point out that this is obviously not a treatment that is working for them... then they point out that I am under-treating them... then i point out that their PCP is over-treating them with a medication that doesn't appear to work... then they either listen to me and follow my instructions or they leave.
do cardiologists who refuse to escalate metoprolol beyond 200mg daily undertreat their BP patients? i don't think so...
under-treatment is way over-used when it comes to narcotics and in my opinion it represents the fixation by some chronic pain patients (and the narcotic drug industry) that if they don't get specifically an increase in narcotics they are being under-treated... some are offended that i would consider adding an NSAID or Neurontin or a TENS unit. I guess they went to medical school and are boarded in pain management...
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It is now not only an issue with patients complaining to their physicians about pain, but is also becoming a legal issue. The more militant pain patients (fortunately a minority) believe they have the RIGHT to unopposed unrestricted narcotic treatment and are beginning to take steps to enfore their "rights". Below are some quotes from internet patient forums from the past 6 months to show what may be the future of patient-physician interactions.
Quote from a national patient advocacy pain forum: all counterpoint responses were deleted by the website moderators leaving the following as their position on the subject: The best advice I can give is that if a doctor isn't giving you enough pain medicine is to complain to the state medical authorities. This may not immediately help you but it will help others who follow because unless several complaints are filed, usually nothing happens. If we just complain on these boards, it will continue to happen. Not being properly medicated is non-treatment of your medical condition. By reporting such incidents, it will help all pain patients. By not reporting, it allows it to continue.
hit THEM where it hurts? Posted: Tuesday, January 09, 2007 They say money talks---i wonder if pockets of folks getting together in class action suits and suing these doctors (who either undertreat their pts. or dismiss them altogether) and actually getting favorable judgements rendered would finally get the attention people in chronic pain so terribly need----another author on this site calls us the silent epidemic----i say raise your voice and raise holy hell
I've also been told my dose is too high even though there is no upper limit for doses of morphine prescribed for chronic pain. Doses can vary from 5mg to 1,000mg every 4 hours, that's up to 6,000mg a day according to the WHO (World Health Org) and with patients in cancer pain it's been prescribed as high as 35,000mg per day without problems of toxicity. I'm on 1,200mg per day and was on 1,600mg before they lowered it! Not to treat chronic pain is unethical and paramount to murder, IMO! erach state has a medical board you can file complaints on doctors with them. Also, for VA, you can file what is called a tort claim, basically suiing them to force them to treat you properly! Send letters to your senators and congressmen and anybody else you can think of!
Quote from a national patient advocacy pain forum: all counterpoint responses were deleted by the website moderators leaving the following as their position on the subject: The best advice I can give is that if a doctor isn't giving you enough pain medicine is to complain to the state medical authorities. This may not immediately help you but it will help others who follow because unless several complaints are filed, usually nothing happens. If we just complain on these boards, it will continue to happen. Not being properly medicated is non-treatment of your medical condition. By reporting such incidents, it will help all pain patients. By not reporting, it allows it to continue.
hit THEM where it hurts? Posted: Tuesday, January 09, 2007 They say money talks---i wonder if pockets of folks getting together in class action suits and suing these doctors (who either undertreat their pts. or dismiss them altogether) and actually getting favorable judgements rendered would finally get the attention people in chronic pain so terribly need----another author on this site calls us the silent epidemic----i say raise your voice and raise holy hell
I've also been told my dose is too high even though there is no upper limit for doses of morphine prescribed for chronic pain. Doses can vary from 5mg to 1,000mg every 4 hours, that's up to 6,000mg a day according to the WHO (World Health Org) and with patients in cancer pain it's been prescribed as high as 35,000mg per day without problems of toxicity. I'm on 1,200mg per day and was on 1,600mg before they lowered it! Not to treat chronic pain is unethical and paramount to murder, IMO! erach state has a medical board you can file complaints on doctors with them. Also, for VA, you can file what is called a tort claim, basically suiing them to force them to treat you properly! Send letters to your senators and congressmen and anybody else you can think of!
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If you want the "full monty" go to painreliefnetwork.org. This is a primary resource for people like the writer for the NYT who wrote the disturbing article on Dr. Hurwitz that was the object of much discussion at the ISIS meeting.
Here is a sample from their FAQ, just so you can get an idea of what they think of us:
Q. Why are there so many pain clinics that dont really treat pain?
A. Because not treating pain is law enforcements preferred approach to pain treatment. Many clinics offer temporary blocks, physical therapy, behavior modification and other techniques. If the clinic refuses to consider opioid therapy to treat your chronic pain, they arent up to date in pain management. Continue your search for state-of-the-art pain care.
Q. My doctor wont give me pain pills but is only offering me an intrathecal pump, that will be surgically implanted in my spinal cord. Ive read that there are risks with these pumps. What do I do?
A. Your doctor has you over a barrel. If you refuse the pump and switch doctors you may be labeled a doctor shopper. Its up to you. All patients in pain find themselves coerced into unnecessarily painful and invasive procedures by health care professionals. This is one of the many dangerous side effects of law enforcement control over medicine.
This is the toned-down version. It used to be much more vitriolic and said we forced people into having painful procedures just to make lots of money from the insurance companies. The founder and driving force is Siobhan Reynolds, whose husband had chronic pain. IIRC, Portenoy was not liberal enough for her with opioids and they went to Hurwitz, who is her hero.
People need to understand that law enforcement is not "anti-pain". Those of us who are old enough to still have our leech jars can recall a time when you literally feared to put someone on 3 Vicodin/day chronically for failed back syndrome, and there were no pumps or stims to fall back on. When I was an intern people would come to the ER literally begging for pain medicine for legitimate complaints and we treated them like dirt.
Today's environment is nothing compared to that. The pendulum has swung the other way and scheduled drugs are freely available all over the place.
Prescription drug abuse and addiction has eclipsed the illegal drugs, and we cannot ignore that. The doctors who are getting into trouble are mostly those without specialty training or certification in pain management. Many of them are family doctors.
Some of them are just dumb. They read articles by guys like Portenoy and swallow them whole. Some are tricked by good actors who are professional drug-seekers. Some are drug addicts themselves who split scripts with patients, some are elderly/senile and have no clue what they are doing, and some are just plain drug dealers.
I have noticed that many of these cases have involved older docs, and that has been noted also by law enforcement. Theories tend to revolve around monetary issues, i.e., that they don't have enough to retire but are out of date and their practices are falling apart. The New Orleans pain clinic case a year or two ago involved exactly that - a nurse running a "pain clinic" with some older docs (most over 65) sitting in a room writing out prescriptions.
Here is a sample from their FAQ, just so you can get an idea of what they think of us:
Q. Why are there so many pain clinics that dont really treat pain?
A. Because not treating pain is law enforcements preferred approach to pain treatment. Many clinics offer temporary blocks, physical therapy, behavior modification and other techniques. If the clinic refuses to consider opioid therapy to treat your chronic pain, they arent up to date in pain management. Continue your search for state-of-the-art pain care.
Q. My doctor wont give me pain pills but is only offering me an intrathecal pump, that will be surgically implanted in my spinal cord. Ive read that there are risks with these pumps. What do I do?
A. Your doctor has you over a barrel. If you refuse the pump and switch doctors you may be labeled a doctor shopper. Its up to you. All patients in pain find themselves coerced into unnecessarily painful and invasive procedures by health care professionals. This is one of the many dangerous side effects of law enforcement control over medicine.
This is the toned-down version. It used to be much more vitriolic and said we forced people into having painful procedures just to make lots of money from the insurance companies. The founder and driving force is Siobhan Reynolds, whose husband had chronic pain. IIRC, Portenoy was not liberal enough for her with opioids and they went to Hurwitz, who is her hero.
People need to understand that law enforcement is not "anti-pain". Those of us who are old enough to still have our leech jars can recall a time when you literally feared to put someone on 3 Vicodin/day chronically for failed back syndrome, and there were no pumps or stims to fall back on. When I was an intern people would come to the ER literally begging for pain medicine for legitimate complaints and we treated them like dirt.
Today's environment is nothing compared to that. The pendulum has swung the other way and scheduled drugs are freely available all over the place.
Prescription drug abuse and addiction has eclipsed the illegal drugs, and we cannot ignore that. The doctors who are getting into trouble are mostly those without specialty training or certification in pain management. Many of them are family doctors.
Some of them are just dumb. They read articles by guys like Portenoy and swallow them whole. Some are tricked by good actors who are professional drug-seekers. Some are drug addicts themselves who split scripts with patients, some are elderly/senile and have no clue what they are doing, and some are just plain drug dealers.
I have noticed that many of these cases have involved older docs, and that has been noted also by law enforcement. Theories tend to revolve around monetary issues, i.e., that they don't have enough to retire but are out of date and their practices are falling apart. The New Orleans pain clinic case a year or two ago involved exactly that - a nurse running a "pain clinic" with some older docs (most over 65) sitting in a room writing out prescriptions.
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Lots of wisdom in this thread, that's for sure....Can't some of this behavior be mitigated by establishing clear expectations with patients about what is and what is not considered "success" with respect to chronic opioid therapy? It should bebeyond "soft" outcomes like VAS or purported functional gains and actual, verifiable increases in functional BEHAVIOR.
Not ALL pain is opioid responsive and therefore opioids are not a long-term solution for all chronic pain syndromes.
Not ALL pain is opioid responsive and therefore opioids are not a long-term solution for all chronic pain syndromes.
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1) I explain to all patients that i feel are good opioid candidates that there is a chance that they may not respond to opioids
2) I also explain to them that if despite multiple attempts with different types of opioids doesn't relieve their pain or that development of tolerance becomes evident, they will be weaned back off
3) then i make sure they understand all the risks of chronic opioid therapy - as well as the expectations that they need to meed to stay on chronic opioid therapy (ie: they need to follow through on other medical recommendations - ie: cognitive therapy, aquatic therapy, smoking cessation, no more alcohol, whatever else...)
4) when somebody starts on opioids in this context then managing them is FAR easier than trying the alternative of having to deal with somebody who comes in with certain expectations
the successful lawsuits for undertreatment of pain were cancer related - and I would think it would be hard to find a pain physician who isn't very liberal when it comes to terminal cancer pain...
If opioids for chronic pain were the golden answer than everybody in Denmark should be pain free - they literally dump narcotics on those patients and now they have a huge Disability/Welfare population (wonder why?) and overall pain control isn't improved - i can't wait till the studies get published on their large population data...
2) I also explain to them that if despite multiple attempts with different types of opioids doesn't relieve their pain or that development of tolerance becomes evident, they will be weaned back off
3) then i make sure they understand all the risks of chronic opioid therapy - as well as the expectations that they need to meed to stay on chronic opioid therapy (ie: they need to follow through on other medical recommendations - ie: cognitive therapy, aquatic therapy, smoking cessation, no more alcohol, whatever else...)
4) when somebody starts on opioids in this context then managing them is FAR easier than trying the alternative of having to deal with somebody who comes in with certain expectations
the successful lawsuits for undertreatment of pain were cancer related - and I would think it would be hard to find a pain physician who isn't very liberal when it comes to terminal cancer pain...
If opioids for chronic pain were the golden answer than everybody in Denmark should be pain free - they literally dump narcotics on those patients and now they have a huge Disability/Welfare population (wonder why?) and overall pain control isn't improved - i can't wait till the studies get published on their large population data...
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and unfortunately a lot of this brouhaha is not motivated by patients but by the brainwashing from the pharmaceutical industry...
studies are coming out on a regular basis showing that opioids are superior to placebo for breakthrough cancer pain.... WOW - BIG SURPRISE
and then I have the FENTORA rep in my office trying to convince me to prescribe this ridiculously expensive drug for break-through back pain on opioid-naive patients - with the mantra that a "lot of pain doctors are doing it now"... Then i point out that the Fentora brochure says "for break-through cancer pain in patients who are not opioid-naive"... then he winks and says that is what they have to put down "legally". He figures if PCPs are willing to precribe vicodin for back pain why not employ a drug that reaches therapeutic levels in 3 minutes ----.... I kicked him out of my office. I will use FENTORA as a LAST step for a dying cancer patient - but I have many tricks up my sleeve before I resort to a drug that costs 3-4k/month for a supply!!!!
oxycontin was such a big money maker for purdue - now everybody and their mother wants to patent a new long-acting agent... clinical trials are going on everywhere (performed by my esteemed pain colleagues who are sabotaging me slowly) including for a new controlled-release vicodin, controlled-release darvocet (are they crazy), controlled-release nubaine... it is insane
we need to educate our community - we need to do CMEs for the PCPs -
i am told all the time that I am under-treating narcotic patients - but I clearly demonstrate in my chart that I am offering many other non-narcotic treatments that the patients frequently refuse.
my favorite (most recent) drug storry: patient prescribed MSIR 200mg Q3 and Oxycodone 80mg q2 per day by their oral surgeon for TMJ --- patient insists that it is the only thing that works - they were referred to me for potential SI joint injection for buttock pain. I smell something fishy and tell the patient i need a drug screen before i can provide a procedure - which they go through with (i was shocked - i thought they would just leave). Of course the screen was negative - and it turns out that they are selling the prescriptions back to the oral surgeon.... these aren't the stories that get printed in the news or on the pain care network (or any of those other phony web sites).
studies are coming out on a regular basis showing that opioids are superior to placebo for breakthrough cancer pain.... WOW - BIG SURPRISE
and then I have the FENTORA rep in my office trying to convince me to prescribe this ridiculously expensive drug for break-through back pain on opioid-naive patients - with the mantra that a "lot of pain doctors are doing it now"... Then i point out that the Fentora brochure says "for break-through cancer pain in patients who are not opioid-naive"... then he winks and says that is what they have to put down "legally". He figures if PCPs are willing to precribe vicodin for back pain why not employ a drug that reaches therapeutic levels in 3 minutes ----.... I kicked him out of my office. I will use FENTORA as a LAST step for a dying cancer patient - but I have many tricks up my sleeve before I resort to a drug that costs 3-4k/month for a supply!!!!
oxycontin was such a big money maker for purdue - now everybody and their mother wants to patent a new long-acting agent... clinical trials are going on everywhere (performed by my esteemed pain colleagues who are sabotaging me slowly) including for a new controlled-release vicodin, controlled-release darvocet (are they crazy), controlled-release nubaine... it is insane
we need to educate our community - we need to do CMEs for the PCPs -
i am told all the time that I am under-treating narcotic patients - but I clearly demonstrate in my chart that I am offering many other non-narcotic treatments that the patients frequently refuse.
my favorite (most recent) drug storry: patient prescribed MSIR 200mg Q3 and Oxycodone 80mg q2 per day by their oral surgeon for TMJ --- patient insists that it is the only thing that works - they were referred to me for potential SI joint injection for buttock pain. I smell something fishy and tell the patient i need a drug screen before i can provide a procedure - which they go through with (i was shocked - i thought they would just leave). Of course the screen was negative - and it turns out that they are selling the prescriptions back to the oral surgeon.... these aren't the stories that get printed in the news or on the pain care network (or any of those other phony web sites).
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I came upon this new twist today. It appears some competely unethical doctors in Houston are "certifying" patient's chronic pain and then finding physicians that will load them up with narcotics. Read and try not to gag...
"There may be some hope. I read a pain organization will certify you are in retratable pain & your need for opiates so doctors will have no reason to fear the DEA. The whole process is done by doctors at the org. In fact, they also have an extensive 30 day plan where they diagnose you, get you on the right meds & recommend a treatment plan & give you all the paperwork. Also they find a doc to treat you when you get back home! I wrote & asked the obvious insurance question & will let you know if I'm going to try to find a way to Houston! They go over all your records & have more tests done if needed.
P.S. Their docs have no problems prescribing you with all the opiates you need. Any druggies reading this need not apply because you have to suffer from chronic pain!!! The bad news about the certification is that it will cost you $100.00 but it will save you alot of headaches in the future. Also, there are several forms for you & your doc to fill out, which can be downloaded. The 30 day thing is inpatient. Either way, you have papers saying that you are a certified pain patient that requires large amounts of opiates & are not a druggie!!! And you have docs & lawyers backing this up as well as a well known pain organization!!!"
Does anyone have any more information on this nonsense so that we can notify the Texas Board of Medical Licensure?
"There may be some hope. I read a pain organization will certify you are in retratable pain & your need for opiates so doctors will have no reason to fear the DEA. The whole process is done by doctors at the org. In fact, they also have an extensive 30 day plan where they diagnose you, get you on the right meds & recommend a treatment plan & give you all the paperwork. Also they find a doc to treat you when you get back home! I wrote & asked the obvious insurance question & will let you know if I'm going to try to find a way to Houston! They go over all your records & have more tests done if needed.
P.S. Their docs have no problems prescribing you with all the opiates you need. Any druggies reading this need not apply because you have to suffer from chronic pain!!! The bad news about the certification is that it will cost you $100.00 but it will save you alot of headaches in the future. Also, there are several forms for you & your doc to fill out, which can be downloaded. The 30 day thing is inpatient. Either way, you have papers saying that you are a certified pain patient that requires large amounts of opiates & are not a druggie!!! And you have docs & lawyers backing this up as well as a well known pain organization!!!"
Does anyone have any more information on this nonsense so that we can notify the Texas Board of Medical Licensure?
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Hi, I'm new to this forum, and came across this thread and felt compelled to reply.
First of all, let me give a brief introduction. I'm a medical resident who will in all likelyhood due a pain fellowship. However, I also suffer chronic pain secondary to the 11 operations I have had on my spine for a spinal cord tumor and spine stabalization.
I have no problem with the majority of the above post, but the first sentence is really disturbing to me. To say that terminal cancer patients are the only people that come close to being undertreated is ridiculous. First of all, to seperate terminal cancer patients from all other pain patients seems very irresponsible. Second, what about a patient that is only allowed 2-3 tablets of IR oxycodone/day by his/her physician, and says it helps somewhat but doesn't cover the entire day? Are you saying this patient must have opiate refractory pain, rather than be undertreated? I have no problem with you saying that a patient who is on 80mg of oxycodone tid or more may be opiate resistant rather than undertreated, but I cannot agree with the way you generalized about every other patient not dieing from terminal cancer. Again, I do agree alot of patients on higher opiate doses may have opiate refractory pain, or even have opiate-induced hyperalgesia, but there are cases of non-cancer pain undertreatment.
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So playing the devils advocate, if the drug company line is there are no limits on dose...why is 80mg oxycontin considered to be refractory pain while 15mg oxycodone a day is not? At what number do we reach the limits on undertreatment and reach opiate induced hypersensitization?
I am not sure we can define these numbers since many chronic pain patients would vigorously debate the fact that opiates may be worsening their pain (through the NMDA receptor) and therefore feel they should be permitted to be medicated to the point of unconsciousness....
I am not sure we can define these numbers since many chronic pain patients would vigorously debate the fact that opiates may be worsening their pain (through the NMDA receptor) and therefore feel they should be permitted to be medicated to the point of unconsciousness....
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Thank you for responding in a mature manor and not jumping on my back for what I wrote. I was mainly just trying to give examples, and did not mean to say that those were specific levels for any kind of cut-off. I just did not agree with that poster's first statement.
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I think I know who this is but I need more info. If it's who I think it is, he has a sign in his waiting room that asks people to kindly not throw their Actiq wrappers on the floor. I have seen some of his patients and I have been astonished at the doses and polypharmacy.
The person I am thinking of is well-meaning and very intelligent, and I have enjoyed my conversations about pain with him even though we have very different views on opioids.
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Teri, believe me, many of the docs in practice on this site believe in the use of opiates to increase functionality and activities of daily living for chronic pain patients with non-malignant pain. We are concerned with the degree of militantism that is occurring from a small but very vocal group of pain patients without scruples. For example below was extracted from an "About Us" section of a national patient advocacy organization:
Establish the National Office and expand the current direct counseling of patients into a 24 hour a day hotline, and win funding of this direct patient service from a third party or foundation.
This goal continues for 2000.
Enrolling at least 100 new physician members and at least 1,000 new pain patient members;
This goal continues for 2000.
Begin a privately maintained, but nationwide, program to identify legitimate intractable pain patients and to provide them with an identification card;
This program has begun.
Begin a nationwide program to enter into cooperative agreements with the State Boards of Medical Examiners and the State Boards of Pharmacy, to recognize the XXXX ID cards;
This program has been changed to supporting the enactment of the Model Intractable Pain Act of the National Federation of State Medical Boards
Continue the development and on-going support of its WEB page on the Internet, including the National Physicians Registry and the National Legal Data Bank; Assemble a Pain Treatment resource data bank, to provide a national source of the medical, scientific and policy information that supports the practice of the comprehensive and holistic treatment of intractable pain;
The WEB site is now in its second generation, through the support of its national sponsors. All sub-goals are in the process of implementation and development in the year 2000.
Begin the publication of a national Newsletter;
The Newsletter has been incorporated in the WEB site.
Establish a national pharmacy for members;
The member On-line Pharmacy will be in place within the next 60 days.
Initiate landmark federal legislation to establish the right to adequate pain treatment as a civil right;
The members , through the xxxxxxx Consortium, is advocating for inclusion of pain patients rights in the Federal Patients Bill of Rights.
Secure grants and sponsorship from foundations, corporations, and qualified individuals sufficient to permanently establish the organizations existence.
Establish the National Office and expand the current direct counseling of patients into a 24 hour a day hotline, and win funding of this direct patient service from a third party or foundation.
This goal continues for 2000.
Enrolling at least 100 new physician members and at least 1,000 new pain patient members;
This goal continues for 2000.
Begin a privately maintained, but nationwide, program to identify legitimate intractable pain patients and to provide them with an identification card;
This program has begun.
Begin a nationwide program to enter into cooperative agreements with the State Boards of Medical Examiners and the State Boards of Pharmacy, to recognize the XXXX ID cards;
This program has been changed to supporting the enactment of the Model Intractable Pain Act of the National Federation of State Medical Boards
Continue the development and on-going support of its WEB page on the Internet, including the National Physicians Registry and the National Legal Data Bank; Assemble a Pain Treatment resource data bank, to provide a national source of the medical, scientific and policy information that supports the practice of the comprehensive and holistic treatment of intractable pain;
The WEB site is now in its second generation, through the support of its national sponsors. All sub-goals are in the process of implementation and development in the year 2000.
Begin the publication of a national Newsletter;
The Newsletter has been incorporated in the WEB site.
Establish a national pharmacy for members;
The member On-line Pharmacy will be in place within the next 60 days.
Initiate landmark federal legislation to establish the right to adequate pain treatment as a civil right;
The members , through the xxxxxxx Consortium, is advocating for inclusion of pain patients rights in the Federal Patients Bill of Rights.
Secure grants and sponsorship from foundations, corporations, and qualified individuals sufficient to permanently establish the organizations existence.
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teri - welcome to the conversation
The reason i separate out terminal cancer because the process is terminal - unlike chronic pain or regular cancer pain. Do pain physicians manage a patient differently when they have bony mets and have 3 weeks to live compared to somebody with 11 prior back surgeries who has 40 years more to live? of course they do.
a patient who tells me that oxycodone gives them relief but that they have frequent valleys between dosings - i won't increase their dose I would just place them on a long-acting opioid... the fact that they get relief does not suggest that they are opioid-refractory - i don't understand your question
there are tons of cases of undertreated non-cancer pain - those patients go to see pain physicians (preferably those who are fellowship trained and board certified instead of some quack) and frequently that under-treatment issue is addressed in one form or another.... however i would say that most patients that I see during consultations are frequently not under-treated: instead most PCPs/Spine Surgeons have already done as much as they could to assist these patients.... and some of the best examples of under-treated non-cancer pain is a MISDIAGNOSIS - I can't tell you how many times i have had referrals for patients with sciatica who in fact had bad hamstring injuries - that is under-treatment in my opinion.
i am talking about patients with chronic pain who are on chronic opioids who state that they are under-treated because opioids aren't shovelled into their mouth by the shovel-full... to re-iterate my previous point, those patients aren't under-treated - those patients belong into a separate category - but under-treated would be the wrong word.
The reason i separate out terminal cancer because the process is terminal - unlike chronic pain or regular cancer pain. Do pain physicians manage a patient differently when they have bony mets and have 3 weeks to live compared to somebody with 11 prior back surgeries who has 40 years more to live? of course they do.
a patient who tells me that oxycodone gives them relief but that they have frequent valleys between dosings - i won't increase their dose I would just place them on a long-acting opioid... the fact that they get relief does not suggest that they are opioid-refractory - i don't understand your question
there are tons of cases of undertreated non-cancer pain - those patients go to see pain physicians (preferably those who are fellowship trained and board certified instead of some quack) and frequently that under-treatment issue is addressed in one form or another.... however i would say that most patients that I see during consultations are frequently not under-treated: instead most PCPs/Spine Surgeons have already done as much as they could to assist these patients.... and some of the best examples of under-treated non-cancer pain is a MISDIAGNOSIS - I can't tell you how many times i have had referrals for patients with sciatica who in fact had bad hamstring injuries - that is under-treatment in my opinion.
i am talking about patients with chronic pain who are on chronic opioids who state that they are under-treated because opioids aren't shovelled into their mouth by the shovel-full... to re-iterate my previous point, those patients aren't under-treated - those patients belong into a separate category - but under-treated would be the wrong word.
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I have always been puzzled by this line of thinking. If you are in severe pain and have 20 days to live, you get pain medicine. If you have severe pain and have 20 years to live, you don't.
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gorback
you may be misrepresenting my point -
if you have 3 weeks to live and have a clear nociceptive process the treatment modalities are going to be different from somebody who does not have clear nociceptive processes who has another 20 years to live....
in a cancer patient who is dying w/ bony mets the end-point of treatment is death -
in a non-terminal patient who has severe pain the end-point of treatment is opioid-tolerance - so let's say you aggressively use opioids to control the patient's pain and now 5 years later they still have the same pain but are on 140mg TID of oxycontin - now what? so that would argue that the strategy for pain control by definition will be different if you look at long-term implications...
sure i can make anybody feel good with heroin but we aren't and shouldn't be short-term thinkers on this.
you may be misrepresenting my point -
if you have 3 weeks to live and have a clear nociceptive process the treatment modalities are going to be different from somebody who does not have clear nociceptive processes who has another 20 years to live....
in a cancer patient who is dying w/ bony mets the end-point of treatment is death -
in a non-terminal patient who has severe pain the end-point of treatment is opioid-tolerance - so let's say you aggressively use opioids to control the patient's pain and now 5 years later they still have the same pain but are on 140mg TID of oxycontin - now what? so that would argue that the strategy for pain control by definition will be different if you look at long-term implications...
sure i can make anybody feel good with heroin but we aren't and shouldn't be short-term thinkers on this.
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Thank you everyone for not jumping on me for my post even though it didn't have the greatest tone.
Tenesma- I must have misunderstood what you wrote. It sounded to me like you were saying that there wasn't such a thing as undertreatment in a non-terminal patient, and that was what I would have disagreed with. I do agree that the term undertreatment is often used incorrectly, and It may be the patient has opiate refractory pain, was misdiagnosed, or is abusing/diverting his/her meds.
Even though I do have chronic pain, I am not entirely pro-opiate.
I believe opiates are just one of many tools a physcian has in his/her arsenal. I feel the theraputic benefit needs to be weighed against the adverse effects and abuse/diversion potential in a particular patient. In my mind,it all comes down to whether or not the patient's quality of life is improved with the opiate.
Tenesma- I must have misunderstood what you wrote. It sounded to me like you were saying that there wasn't such a thing as undertreatment in a non-terminal patient, and that was what I would have disagreed with. I do agree that the term undertreatment is often used incorrectly, and It may be the patient has opiate refractory pain, was misdiagnosed, or is abusing/diverting his/her meds.
Even though I do have chronic pain, I am not entirely pro-opiate.
I believe opiates are just one of many tools a physcian has in his/her arsenal. I feel the theraputic benefit needs to be weighed against the adverse effects and abuse/diversion potential in a particular patient. In my mind,it all comes down to whether or not the patient's quality of life is improved with the opiate.
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Teri, where are you doing your residency?
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What a defeatist and cynical concept.
What will you do for the patient with rheumatoid arthritis (non-terminal, defined pathology)? Inject every joint in their body? Based on your previous posts I think I know the answer to this one. You will refer them back to their PCP and let someone with no pain management experience try to struggle their way through chronic opioid therapy.
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i think the flaw in the assumption here is that chronic opioids are the "golden rule" for chronic pain... and that is a flawed assumption (in my opinion).
If somebody with chronic pain issues has tried multiple modalities (all of which have failed) then i would consider chronic opioids as a last resort approach (which i think most of us would agree on) - if they demonstrate some sort of control with chronic opioids and dont display any red flag behaviors then I think chronic opioids make sense. I will frequently set up a game plan for the PCP and if there are any issues with the patient or their management, the patient gets bounced back to me for re-evaluation (so technically the PCP isn't struggling).
the reality is that for a lot of chronic pain patients we can give them some type of relief with opioids - but what is your plan for them going to be 5 years from now?
and if opioids are so great for chronic intractable pain, why is it that I can successfully wean so many patients off their opioids and they actually thank me? In fact i have a guy i saw yesterday with cervical AND lumbar post-laminectomy syndrome who I have weaned off oxycontin completely who is now on 1 vicodin PRN (once a week or so) for exacerbations - and he couldn't be happier (of course he was pissy during the transition phase). His pain is EXACTLY the same but he doesn't have to take the narcotics anymore, doesn't have to deal with constipation and sexual dysfunction anymore, doesn't feel fogged anymore.... now of course this could never be achieved with those chronic pain patients who are "chemical copers" - just the mere threat of weaning their opioids and they turn into a snake that has been cornered. and those are the patients who deserve better psychological interventions (of course they will be resistant to it).
there must be something behind this, because as my rep grows as being anti-narcotics (for 90% of cases - i am still pro-narcotics for certain situations) I am actually getting tons of Self-Referrals from chronic pain patients who want to come off their narcotics...
teri - i agree with you
If somebody with chronic pain issues has tried multiple modalities (all of which have failed) then i would consider chronic opioids as a last resort approach (which i think most of us would agree on) - if they demonstrate some sort of control with chronic opioids and dont display any red flag behaviors then I think chronic opioids make sense. I will frequently set up a game plan for the PCP and if there are any issues with the patient or their management, the patient gets bounced back to me for re-evaluation (so technically the PCP isn't struggling).
the reality is that for a lot of chronic pain patients we can give them some type of relief with opioids - but what is your plan for them going to be 5 years from now?
and if opioids are so great for chronic intractable pain, why is it that I can successfully wean so many patients off their opioids and they actually thank me? In fact i have a guy i saw yesterday with cervical AND lumbar post-laminectomy syndrome who I have weaned off oxycontin completely who is now on 1 vicodin PRN (once a week or so) for exacerbations - and he couldn't be happier (of course he was pissy during the transition phase). His pain is EXACTLY the same but he doesn't have to take the narcotics anymore, doesn't have to deal with constipation and sexual dysfunction anymore, doesn't feel fogged anymore.... now of course this could never be achieved with those chronic pain patients who are "chemical copers" - just the mere threat of weaning their opioids and they turn into a snake that has been cornered. and those are the patients who deserve better psychological interventions (of course they will be resistant to it).
there must be something behind this, because as my rep grows as being anti-narcotics (for 90% of cases - i am still pro-narcotics for certain situations) I am actually getting tons of Self-Referrals from chronic pain patients who want to come off their narcotics...
teri - i agree with you
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algosdoc- I really do not like to give out that type of infor over a public forum. My residency location,however, really is not a reflection upon what I know/don't know about opiates and pain management. That really isn't something that is covered very well. The majority of my experience on the subject has come from spending several months in a pain clinic working with a well-know academic physcian. It also comes from more than a decade as a patient in pain management. Due to the severity of my pathology, I have never been treated poorly by any physcian, so my views on opiates are not tainted with bitterness.
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Chronic opiates are one piece of the puzzle in pain treatment. It would be nice if there were some reasonable studies to support their use long term. Most of us prescribe these drugs on a long term basis, but perhaps you, having been on both sides of the fence, will be able to organize the evidence based medicine studies (longer than 16 weeks) that would demonstrate some improvement functionally, psychologically, and perhaps even in the measurement of pain (however that is best done...). Welcome to the relatively small club of pain physicians in the US...
Hi all,
I found this entire conversation informative. I was carrying a computer server (200#) alone in the snow back in 1995. Computer started to elude my grasp, I put my right leg back at about a 45d angle to save the computer, and in the process ruptured my L3-L4-L5.
I'm not a doctor, so the term "ruptured" may not be the correct nomenclature. Looking at the various MRI's over the years, the "discs" between the vertebrae appear somewhat rectangular, until you get down to L3-L4-L5, then they are more appropriately described as "triangular" with a cloud of "stuff" coming out.
I found this entire conversation informative. I was carrying a computer server (200#) alone in the snow back in 1995. Computer started to elude my grasp, I put my right leg back at about a 45d angle to save the computer, and in the process ruptured my L3-L4-L5.
I'm not a doctor, so the term "ruptured" may not be the correct nomenclature. Looking at the various MRI's over the years, the "discs" between the vertebrae appear somewhat rectangular, until you get down to L3-L4-L5, then they are more appropriately described as "triangular" with a cloud of "stuff" coming out.
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J Pain. 2005 Oct;6(10):662-72.
Trends in abuse of Oxycontin and other opioid analgesics in the United States: 2002-2004.
Cicero TJ, Inciardi JA, Muñoz A.
Source
Washington University School of Medicine, St. Louis, Missouri 63110, USA. [email protected]
Abstract
OxyContin (Purdue Pharma L.P., Stamford, Conn) was approved by the Food and Drug Administration (FDA) in 1995 as a sustained-release preparation of oxycodone hydrochloride and was thought to have much lower abuse potential than immediate-release oxycodone because of its slow-release properties. However, beginning in 2000, widespread reports of OxyContin abuse surfaced. In response, Purdue Pharma L.P. sponsored the development of a proactive abuse surveillance program, named the Researched Abuse, Diversion and Addiction-Related Surveillance (RADARS) system. In this paper, we describe results obtained from one aspect of RADARS--the use of drug abuse experts (ie, key informants)--as a source of data on the prevalence and magnitude of abuse of prescription drugs. The results indicate that prescription drug abuse has become prevalent, with cases reported in 60% of the zip codes surveyed. The prevalence of abuse was rank ordered as follows: OxyContin >or= hydrocodone > other oxycodone > methadone > morphine > hydromorphone > fentanyl > buprenorphine. In terms of the magnitude of abuse (>or=5 cases/100,000 persons in a 3-digit zip code), modest growth was seen with all analgesics over the 10 calendar quarters we monitored, but was most pronounced with OxyContin and hydrocodone. These results indicate that OxyContin abuse is a pervasive problem in this country, but that it needs to be considered in the context of a general pattern of increasing prescription drug abuse. PERSPECTIVE: Over the past 5 years, there have been reports, frequently anecdotal, that opioid analgesic abuse has evolved into a national epidemic. In this study, we report systematic data to indicate that opioid analgesic abuse has in fact increased among street and recreational drug users, with OxyContin and hydrocodone products the most frequently abused. Steps need to be taken to reduce prescription drug abuse, but very great care needs to be exercised in the nature of these actions so the legitimate and appropriate use of these drugs in the treatment of pain is not compromised as a result.
PMID: 16202959 [PubMed - indexed for MEDLINE]
Trends in abuse of Oxycontin and other opioid analgesics in the United States: 2002-2004.
Cicero TJ, Inciardi JA, Muñoz A.
Source
Washington University School of Medicine, St. Louis, Missouri 63110, USA. [email protected]
Abstract
OxyContin (Purdue Pharma L.P., Stamford, Conn) was approved by the Food and Drug Administration (FDA) in 1995 as a sustained-release preparation of oxycodone hydrochloride and was thought to have much lower abuse potential than immediate-release oxycodone because of its slow-release properties. However, beginning in 2000, widespread reports of OxyContin abuse surfaced. In response, Purdue Pharma L.P. sponsored the development of a proactive abuse surveillance program, named the Researched Abuse, Diversion and Addiction-Related Surveillance (RADARS) system. In this paper, we describe results obtained from one aspect of RADARS--the use of drug abuse experts (ie, key informants)--as a source of data on the prevalence and magnitude of abuse of prescription drugs. The results indicate that prescription drug abuse has become prevalent, with cases reported in 60% of the zip codes surveyed. The prevalence of abuse was rank ordered as follows: OxyContin >or= hydrocodone > other oxycodone > methadone > morphine > hydromorphone > fentanyl > buprenorphine. In terms of the magnitude of abuse (>or=5 cases/100,000 persons in a 3-digit zip code), modest growth was seen with all analgesics over the 10 calendar quarters we monitored, but was most pronounced with OxyContin and hydrocodone. These results indicate that OxyContin abuse is a pervasive problem in this country, but that it needs to be considered in the context of a general pattern of increasing prescription drug abuse. PERSPECTIVE: Over the past 5 years, there have been reports, frequently anecdotal, that opioid analgesic abuse has evolved into a national epidemic. In this study, we report systematic data to indicate that opioid analgesic abuse has in fact increased among street and recreational drug users, with OxyContin and hydrocodone products the most frequently abused. Steps need to be taken to reduce prescription drug abuse, but very great care needs to be exercised in the nature of these actions so the legitimate and appropriate use of these drugs in the treatment of pain is not compromised as a result.
PMID: 16202959 [PubMed - indexed for MEDLINE]
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Read: We want to have our cake and it it, too.
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